Provider Demographics
NPI:1184816233
Name:RICHARD, JUANITA MAE (M ED)
Entity type:Individual
Prefix:
First Name:JUANITA
Middle Name:MAE
Last Name:RICHARD
Suffix:
Gender:F
Credentials:M ED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15082 N 59TH AVE APT 157
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85306-5234
Mailing Address - Country:US
Mailing Address - Phone:623-297-7686
Mailing Address - Fax:
Practice Address - Street 1:15082 N 59TH AVE APT 157
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85306-5234
Practice Address - Country:US
Practice Address - Phone:623-297-7686
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-13
Last Update Date:2007-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist